When caring for transgender people, you can approach clinical decision-making using the same physiological principles you would apply to cisgender individuals with comparable hormone profiles.
Transgender people on hormone therapy have simply adjusted their hormone balance to align with their gender identity meaning that they will have the same hormonal risk profile as their cisgender counterparts.
Key Principles:
Trans feminine people (on oestrogen) should be treated in the same way as cis women with an oestrogen profile originating from their ovaries.
Trans masculine people (on testosterone) should be treated in the same way as cis men with a testosterone profile originating from their testicles.
Risk Management
The following risk examples should be managed using the same clinical protocols you would use for cisgender people with the same hormone profile:
Hormone-dependent cancers
Thrombosis
Cardiovascular events
Example:
A cis woman with a blood clot would not routinely have her oestrogen suppressed, and the same applies to a trans woman and there is no need to stop her oestrogen.
A cis woman with breast cancer would likely need oestrogen suppression, and the same applies to a trans woman, she should avoid having oestrogen..
If there is no clinical indication to suppress a cis person’s hormones, there should be no indication to stop a trans person’s gender-affirming hormones.
Common Medications in Gender-Affirming Care:
You may encounter trans people taking:
Spironolactone – risk of hyperkalaemia, dehydration, low blood pressure, dizziness. Avoid using other antihypertensives or cardiology medications. Regular U&Es are recommended.
Cyproterone acetate – liver toxicity. Regular LFTs are recommended..
GnRHa (puberty blockers) – risk of low bone density, hot flushes, mood changes - ensure concomitant hormone levels are adequate.
Side effects, risks, and management should be exactly as they would be for cis people taking the same medications for other reasons.
Monitoring Hormone Levels:
Oestrogen and testosterone levels should be within the physiological range for the affirmed gender.
If there are concerns, trans individuals can upload their latest hormone results, U&Es, LFTS via our website for review.
When to Change Medications:
If an anti-androgen or anti-oestrogen is stopped for medical reasons, alternatives should be selected based via our electronic systems.
The Risks of Unnecessary Hormone Suppression:
Just as suppressing hormones in cis people can increase the risks of:
Osteoporosis and poor bone health
Cardiovascular disease
Cognitive decline and dementia
The same risks apply to trans people if hormones are unnecessarily stopped or withheld. Additionally, withholding gender-affirming hormones can lead to:
Worsening mental health
Increased risk of depression, self-harm and suicide
Reduced quality of life and life satisfaction
Clinical Reminder:
Always remember that for trans people, their hormone profile is simply swapped to align with their identity.
Their clinical care should align with the physiology in front of you, not their sex assigned at birth.
If in doubt, treat them as you would any person with that hormone profile.
Common Scenarios
When caring for transgender people on gender-affirming hormones, clinical management should follow the same protocols as for cisgender people with comparable hormone profiles. Below are some typical scenarios and the appropriate responses.
Case Examples and Clinical Actions
1. Venous Thromboembolism (VTE – e.g., DVT or PE)
Investigate and treat as you would for any patient.
No indication to routinely stop gender-affirming hormones.
Risk should be balanced as it would be for a cisgender person.
2. Breast Cancer
Gender-affirming hormones should usually be stopped.
This follows the same approach as in cisgender women with hormone-sensitive breast cancer.
Alternative options or risk-reducing strategies can be discussed on a case-by-case basis.
3. Dizziness on Spironolactone
Consider switching to an alternative anti-androgen.
Alternatives may include:
Finasteride
GnRHa
Manage side effects as you would in cisgender patients using the same medications.
4. Depression
Treat the depression appropriately, as you would in any patient.
Consider that maintaining or optimising gender-affirming hormone therapy may improve mental health outcomes.
Gender-affirming care should not be withheld or deprioritised in cases of depression.
5. Myocardial Infarction (MI) or Stroke
Ensure hormone levels are within physiological ranges for their affirmed gender and age.
Hormone therapy is not automatically contraindicated.
Management should be risk-assessed as you would for a cis person with that natural hormone profile, focusing on hormone dose, transdermal delivery methods, and overall cardiovascular health.
Key Clinical Reminders:
Hormone suppression is not routinely required unless it would also be recommended for a cisgender person with the same hormone profile and condition.
Unnecessarily stopping gender-affirming hormones can worsen mental health and reduce life satisfaction.
Always prioritise physiological safety and gender affirmation.